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Based on clinical record review, staff interview and facility policy/procedure review, the facility staff failed to ensure restraints were implemented per physician's orders for two (2) of four (4) records reviewed for the use of restraints. Patient # 1 and Patient #2.

For both patients, the staff were documenting the use of a restraint, for which there was no physician's order.

The findings included:

Patient #1 had a physician's order for the use of "soft restraints, all extremities" on 2/26/2020. According to documentation of monitoring the patient was documented as having "bedrails" and "soft- all extremities". Every two hour monitoring evidenced the patient was in the "soft restraints" as well as "bedrails".

Patient #2 had a physician's order for "soft BUE (bilateral upper extremities)" on 3/6/2020. According to monitoring documentation in the clinical record the staff had documented the patient was not only in the "soft BUE" restraints, but also had "bedrails" under "restraint devices".

The facility policy and procedure "Seclusion, Restraints and Restraint Alternatives" was reviewed and evidenced, in part: "...5. Order for restraint or seclusion...a. An order for restraint or seclusion must be obtained from a LIP (Licensed Independent Practitioner)/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release...7b..A RN (Registered Nurse) will assess the patient at least every two (2) hours..."

During the chart reviews with Staff Member #12 on 3/11/2020 between 9:45 a.m. and 10:45 a.m., the surveyor discussed the findings.

On 3/12/2020 at 12:15 p.m. the findings were again discussed with Staff Members #1 (Vice President of Quality), Staff Member #2 (Chief Medical Officer), Staff Member # 33 (Peer review Coordinator), Staff Member # 32 (Quality), Staff Member # 3 (Director of Risk and Patient Safety), Staff Member # 31 (Chief Nursing Officer), and Staff Member #30 (Assistant Chief Nursing Officer).

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to ensure an effective and safe discharge plan was implemented for one (1) of three (3) patients (Patient #18). Due to the severity of the deficiency, the facility failed to substantially comply with this condition.

See tag A-0802

Based on clinical record reviews, staff interview and document review, it was determined the facility staff failed to ensure one (1) of three (3) patient's (Patient #18) discharge plan was reassessed after the original discharge planning evaluation was completed.

The findings include:

Patient #18's initial discharge plan evaluation reflected that home health services was a need. The discharge plan did not reveal any evidence that home health services were no longer a need nor that home health services were initiated for Patient #18 post-discharge. Review of the "Case Management Note" dated 2/18/19 at 1510 (3:10 p.m.) evidenced a Case Manager (Staff Member #23) spoke with Patient #18 who was "confused and unable to provide reliable information." SM #23 asked Patient #18 about an individual's name that was listed on Patient #18's facesheet. Patient #18 stated that individual "was not involved." SM#23 documented that an attempt was made to contact the individual listed on the facesheet, but the phone was out of service. SM #23 further documented that per a previous note in Patient #18's chart, Patient #18 had no other durable medical equipment other than home oxygen. SM#23 documented a discharge planning evaluation that was completed for Patient #18. Home health was identified as a need and inadequate housing was identified as a discharge barrier. On 2/27/19 1314 (1:14 p.m.) a case management note evidenced that Staff Member #23 was notified by bedside registered nurse that physical therapy advised Patient #18 needs a rehabilitation setting. It was further evidenced in the note that Patient #18 refused to consider rehabilitation and has no other residence at this time.

The clinical record revealed documentation that Patient #18's capacity to make medical decisions were questionable and that pursuing guardianship was recommended. The discharge plan did not reveal any evidence that guardianship was in pursuit or that any action was taken in regards to Patient #18's incapacity to make medical decisions. A 2/21/19 clinical note documented at 0931 (9:31 a.m.) evidenced in part: "...dispo (disposition) Patient #18 is unsafe for discharge due to Patient #18's mental status which may be chronic. We have no family or MPOA (Medical Power of Attorney) at this time." A Psychiatric consultation note on 3/4/19 at 1608 (4:08 p.m.) evidenced in part, "Poor attention, likely delusional themes and does not have clear understanding of medical issue and risk benefits of treatment plan. Cognitive impairment {sic} with atrophy on CT (computed tomography) head. IMO (in my opinion), Patient #18 currently lacks capacity to make medical decision {sic}." On 3/5/19 at 1219 (12:19 p.m.), a case management note evidenced that Case Manager, (Staff Member #24) documented that Patient #18 was seen by pysch on 3/4/19 and "they say Patient #18 is not competent to make decisions cm (case management) has not been able to locate patients {sic} family. Patient #18 needs guardianship placement. cm {sic} following." On 3/6/19 at 1633 (4:33 p.m.), a clinical note evidenced in part, "Disposition CRM to help with placement. Needs guardianship, has no capacity to make medicinal decision {sic}."

The clinical record also revealed documentation that Patient #18 was supplemented with oxygen via a nasal cannula during the hospitalization. The discharge plan instructions revealed that Patient #18 was dependent on supplemental oxygen; however, the discharge plan did not reveal any evidence that supplemental oxygen was arranged for Patient #18 upon discharge. A clinical note on 2/18/19 at 0914 (9:14 a.m.) evidenced that Patient #18 "leaves {sic} alone and gets help from friends. Patient #18 could not say names but remembers address."

On 3/11/20 at 1:25 p.m. an interview was conducted with the Director of Case Management (Staff Member #22). The surveyor asked if the original discharge planning evaluation required amendment during the course of the hospital stay, how is this accomplished? Per Staff Member #22, the case management notes would reflect any new patient needs and/or changes to the original evaluation. In regards to obtaining guardianship for a patient, Staff Member #22 stated, "There are multiple steps in the process. Two (2) physicians must document the patient's inability to make decisions. The case manager must exhaust a family search which can sometimes include contacting a law office for assistance. The process takes approximately one (1) month." The surveyor asked how a patient can designate a representative to contact on their behalf during the hospitalization. Staff Member #22 responded, "If a patient designates a representative, case management will free text that information in the narrative notes." In regards to the patient's discharge needs, Staff Member #22 stated, "Case managers are responsible for determining needs, i.e. oxygen in the home, etc." Staff Member #22 was not familiar with Patient #18; however, when the surveyor asked Staff Member #22 if there was a patient who Staff Member #22 had experienced difficulty contacting the family and on the day of discharge an unidentified individual shows up at the facility identifying themselves as the patient's adult child, how would Staff Member #22 handle the situation. Staff Member #22 stated, "I would assess the interaction between the patient and this person. I would inform this person that we have been trying to locate the patient's family but have had difficulty. I would then ask this person where have they been and how did they know the patient was being discharged."

On the date of discharge, 3/11/19, Patient #18 was documented as being sent home with an "adult child". There was no documentation found in the clinical record of any successful contact and/or location of an adult child for Patient #18, there was no follow-up documentation from discharge planning as to who the individual was, or where Patient #18 would be going after discharge.

Contained in the discharge instructions was a note indicating that one of Patient #18's medical problems was supplemental oxygen dependence. The brief discharge note dated 3/11/19 documented vital signs that were taken the morning of discharge and indicated Patient #18 was on two (2) liters of oxygen via a nasal cannula. There was no evidence contained in the clinical record that any follow-up was conducted as to whether Patient #18 still required supplemental oxygen, or how it would have been delivered to the patient, as there was no residential address or DME (Durable Medical Equipment) request or evaluation.

The survey team discussed the concerns regarding the discharge with the facility Administration on 3/12/20 at 12:00 p.m.

The facility policy/procedure "Discharge Planning in the Continuation of Care" was reviewed and evidenced, in part: " ...All patients are screened to determine discharge planning needs. Discharge planning involves the patient, the family, the practitioner primarily responsible for the patient or the physician consultant, nursing case management/social work professionals, and other appropriate staff ....discharge planning focuses on meeting patients' health care needs after discharge ..."

The facility policy "Utilization Management Plan" documented, in part: " ...The process of discharge planning begins prior to or at admission for all patients. A discharge evaluation is performed by case management on patients identified as needing discharge planning ...the Case Manager works with the Attending physician, the patient, the patient's family and appropriate hospital departments to ensure continuity of care post discharge ....The Case Manager assesses discharge planning in a timely manner and prior to discharge and initiates discharge planning of nursing home or rehabilitation placement, durable medical equipment, home health care. Hospice, transportation, or other discharge needs are identified. Discharge planning activities include provisions for request of services required to improve or maintain health status post discharge."

Review of the facility policy "Discharge of Patients" revealed, in part: "C. Discharge Planning shall begin at the time pf admission and is an ongoing process of determining patient/family needs to provide continuity of care ...Review discharge instructions with the patient/significant other ...note time of discharge/mode of discharge/accompanied by whom ..."